A nurse on a postpartum unit is caring for a group of clients. Which of the following clients is the nurse’s priority?
A client who is 2 days postpartum and whose fundus is 2 to 4 cm below the umbilicus.
A client who is 3 days postpartum and has not had a bowel movement since prior to admission.
A client who is 4 days postpartum and has lochia serosa.
A client who is 1 day postpartum and has not voided in 8 hr.
The Correct Answer is D
A client who is 1 day postpartum and has not voided in 8 hr. This client is at risk of urinary retention, bladder distension, and infection due to the effects of epidural anesthesia, perineal trauma, and fluid shifts after delivery. The nurse should assess the client’s bladder and catheterize if necessary.
Choice A is wrong because a client who is 2 days postpartum and whose fundus is 2 to 4 cm below the umbilicus is showing a normal finding.
The fundus should descend about 1 to 2 cm per day after delivery and be nonpalpable by day 10.
Choice B is wrong because a client who is 3 days postpartum and has not had a bowel movement since prior to admission is not uncommon.
Constipation is a common problem after delivery due to decreased peristalsis, dehydration, and fear of pain.
The nurse should encourage fluid intake, fiber intake, and early ambulation to promote bowel function.
Choice C is wrong because a client who is 4 days postpartum and has lochia serosa is also showing a normal finding.
Lochia serosa is the pinkish-brown discharge that occurs from day 4 to 10 after delivery.
It consists of old blood, serum, leukocytes, and tissue debris.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Insulin lispro was administered to a client immediately before bed. This is a situation that requires the completion of an incident report because insulin lispro is a rapid-acting insulin that should be given within 15 minutes before or after a meal. Giving it immediately before bed can cause hypoglycemia (low blood sugar) during the night, which can be dangerous for the client.
Choice A is wrong because nitroglycerin transdermal is a medication used to prevent angina (chest pain) and can be applied to a client’s chest as prescribed.
Choice B is wrong because cefotaxime is an antibiotic that can be administered to a client after obtaining blood cultures to treat an infection.
Choice C is wrong because digoxin is a medication used to treat heart failure and atrial fibrillation and can be administered to a client who has a heart rate of 64/min, which is within the normal range of 60 to 100 beats per minute.
Correct Answer is B
Explanation
Encourage the client to visit with someone who has had an amputation.
This strategy can help the client cope with the loss of a body part and learn from the experience of others who have gone through a similar situation.
Choice A is wrong because suggesting that the client wear facility clothing until the prosthesis fitting can delay the client’s acceptance of the body image alteration and increase the risk of infection.
Choice C is wrong because discouraging the client from touching the residual limb for the first week can interfere with the healing process and prevent the client from becoming familiar with the new body part.
Choice D is wrong because reassuring the client that the rehabilitation program is optional can discourage the client from participating in physical therapy and hinder the recovery and adaptation.
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